ED-Initiated Buprenorphine Cost-Effective for Opioid Dependence

Initiating buprenorphine in the emergency department (ED), followed by ongoing primary care with buprenorphine, is cost-effective for patients with opioid dependence, researchers report.

“On average, even though more people in the ED-initiated treatment group were still receiving treatment at 30 days, there were no significant differences in total healthcare costs at 30 days,” Dr. Susan H. Busch from Yale School of Public Health, New Haven, Conn., told Reuters Health by email. “ED-initiated treatment led to better outcomes (i.e., more people in treatment), with no measurable differences in healthcare costs.”

Buprenorphine is one of multiple effective treatments available for opioid dependence, but only 11 percent of people who need emergency treatment related to drug or alcohol use go on to receive it at a specialty facility.

In a recent study, Dr. Busch and colleagues showed that opioid-dependent patients receiving ED-initiated buprenorphine-naloxone had better outcomes than people who received interventions that did not include immediate buprenorphine-naloxone.

Their new report, published online August 16 in Addiction, involved 329 opioid-dependent patients treated at an urban teaching hospital ED. The researchers evaluated the costs and effects of three approaches: (1) screening, brief intervention, ED-initiated treatment with buprenorphine-naloxone, and referral to primary care for 10-week follow-up (“buprenorphine”); (2) screening, brief intervention, and facilitated referral to community-based treatment services (“brief intervention”); and (3) screening and referral to treatment (“referral”).

After ED discharge, the buprenorphine group used more drug addiction-specific, office-based services, while the referral and brief-intervention groups used more resources based at addiction treatment centers. Despite these differences in use of services, total healthcare costs differed only slightly and nonsignificantly among the groups, although point estimates were lowest in the buprenorphine group.

Because outcomes were also superior in the buprenorphine group, referral and brief intervention were found to be much less cost-effective. Moreover, ED-initiated buprenorphine outperformed the other treatments at all willingness-to-pay levels.

“Getting individuals in to evidence-based treatments should be a priority for all health care stakeholders,” Dr. Busch said by email. “Yet, healthcare costs in the U.S. are high, and there is concern that some of the care provided may be low-value.”

“From our original study, we knew this treatment was effective,” she said. “We wanted to test whether it should be considered low- or high-value by insurers or others deciding whether to adopt initiation of this treatment in the emergency department if appropriate. We thought information about the relative costs of these interventions would be useful to organizations such as health insurers and emergency departments.”

Medicinal Cannabis is also effective in helping opioid dependent
people reduce or eliminate their use of opioids.
There are drug treatment centers who use methadone, buprenorphine and medical cannabis for trading opioid dependency.
I wonder how many emergency physicians exercise their First Amendment Right and recommended cannabis for chronic pain, chemotherapy induced nausea and multiple sclerosis.

Studies such as these fail to reflect the realities on the ground for most hospitals and the healthcare system at large. It is helps soothe us into neglecting the greater effort of finding out why we as a country have the highest drug use rates in the world. Patient after patient comes in from every socioeconomic background essentially telling me their right to engage in using everything from cocaine to opioids for “recreation”. It is their rite of passage in college or business trip social gatherings. When these patients become addicts despite our warnings, society rings its hands and says we have an epidemic, a country in the throes of a terrible disease. Of course there are those who fell into the addiction morass because of our opioid over prescribing (also fueled by studies that told us how woefully mismanaged our pain care was, a missed “vital sign”). There are those who succumbed due to socioeconomic circumstances. However, how does that explain the 20-year old suburbanite who was bored and got hooked? These backend ED approaches are no different than take home goodie bags of narcan and the STD tx rx we give to patients’ sexual partners who we never lay eyes on and whose allergies are never reviewed. Never mind that the underlying issue of how why or how this person has an STD is never adequately addressed and that it sets a precedent of infantilizing patients.

People often come to the ED because of predictable yearly limited to nonexistent access to primary care providers, specialists and mental health providers. We have truly limited resources to meet the care of a rapidly aging population who will need more homecare, medications and nursing home care than any group in history. We have obesity bringing diabetes, hypertension and orthopedic troubles to younger populations. It is commonplace to see a person in their 30s tell you about their CPAP machine. Even if our healthcare systems were not plagued by the uncertainties of political rancor and discordant priorities we still would still face limited access to all areas of healthcare including ancillary support. If you’re in a rural area, good luck, it’s even worse. It is time we look at ourselves and patients as part of an entire system with limited resources and realize that we are reaching a point where there is either money for mom’s chemotherapy or payment for twenty people to get a couple months of opioid treatment. They are both serious healthcare needs so why don’t we address that instead, starting at the assumption compromise will be needed.

So yes, let us publish another article about what an academic center can do in a controlled study and have this splashed on the major news networks sites (this usually gets picked up by an online newsfeed) so our patients can come in and ask for a drug I know many of them abuse already. Let’s talk about if we only put more money into various resources how we can change things even though we spend more per capita on healthcare with worse results across the board. Let’s make this another standard of care so we feel we’ve made a difference when it will in the end only help us feel better. I’m sorry, but this does nothing to educate or help ED providers. I want to hear about better models of prevention not how a tightly controlled study that can’t be widely replicated without taking health resources from another group (we have millions struggling with opioid addiction) worked so well.